- Care home
Grove Court
Report from 4 June 2024 assessment
Contents
On this page
- Overview
- Shared direction and culture
- Capable, compassionate and inclusive leaders
- Freedom to speak up
- Workforce equality, diversity and inclusion
- Governance, management and sustainability
- Partnerships and communities
- Learning, improvement and innovation
Well-led
During our assessment of this key question, we found although the provider was working on an action plan, improvements were still needed to ensure governance and assurance systems were effective. The management team had been implementing a programme of improvements and were working with staff to ensure they knew how to use new systems and procedures. The provider had procedures in place to ensure staff felt valued and could raise any issues affecting their work; and had procedures in place to promote staff wellbeing and worked with staff to ensure they could perform at the best of their abilities. The provider worked with health and social care partners to ensure people achieved positive outcomes and continued to work with partners to drive improvements at the service.
This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.
Staff told us the provider had a shared vision to improve the service in which they felt included.
Staff received training in equality and diversity. They understood about equality and diversity and wanted to provide compassionate care. During our assessment, staff demonstrated respect for each other and the people they were supporting. The management team had been implementing a programme of improvements and were working with staff to ensure they knew how to use new systems and procedures. The provider was working with health and social care partners to ensure people were able to maximise their independence and improve outcomes.
Capable, compassionate and inclusive leaders
Staff told us they were supported by the leadership team and felt valued. One staff member told us, “Since the new interim manager came in, things have got so much better. There is more support and understanding.” Another staff member told us, “I used to feel like staff would be jumped on for one wrong move however things have improved a lot under the new management team. I can go to the interim manager or operations manager about anything.”
The provider was in the process of recruiting a registered manager at the time of our assessment. An interim manager was in place and had been supporting the provider to make improvements. The provider had procedures in place to ensure staff felt valued and could raise any issues affecting their work.
Freedom to speak up
Staff understood whistleblowing procedures and felt confident the manager would act on concerns.
The provider had a whistleblowing policy which staff understood. Staff were able to report concerns in one-to-one meetings and the manager had an open-door policy.
Workforce equality, diversity and inclusion
Staff told us they felt the managers valued and respected them, treated them fairly, and listened to their concerns. One staff member told us, “Management supported me through a difficult time and allowed me the time to recover.” Another staff member told us, “The operations manager is amazing. I never feel silly for approaching them about anything. They go above and beyond for everybody.”
The provider had procedures in place to promote staff wellbeing and worked with staff to ensure they could perform at the best of their abilities.
Governance, management and sustainability
The management team told us they were making improvements to their systems following visits from the local authority quality assurance team.
Although the provider was working on an action plan, improvements were still needed to ensure governance and assurance systems were effective. Where a care plan was not updated to reflect a change in a person’s skin needs, this was not identified in care plan audits. Where a person required their feet to be monitored weekly following an incident investigation, audits of care had not identified this had not been taking place. This meant the provider could not be assured people were receiving consistent care which met their needs. Where the provider had identified concerns about a person’s understanding of the risks of accessing the community, a mental capacity assessment and DoLS referral had not been done. Infection prevention and control audits had not identified refrigerated food items were not labelled with opened dates. This meant the provider could not be assured people were not at risk from eating unsafe foods. Medicines audits had not identified some medicines refrigerator temperature records had fallen below the recommended range and that the monitoring log used by staff did not include information about the recommended storage range. This meant the provider could not always be assured issues would be escalated when required. Environmental audits had not identified discarded contents from renovations between the external office and garden space and a pile of loose bricks at knee level and on the ground adjacent to the garden wall. This meant the provider could not always be assured people were safe from the home environment. While the provider had identified some staff had not completed their refresher training and had discussed this with the affected staff, the provider had not ensured training had been completed in a timely way. This meant the provider could not be assured people were receiving consistently safe and effective care.
Partnerships and communities
People told us the provider worked well with partner agencies in relation to their care.
Staff told us they worked well with partner agencies, made referrals, and followed their recommendations when needed to meet people’s needs. One staff member told us, “We make referrals to partner agencies and work closely with them to review people’s needs and risks.”
While some feedback from professionals visiting the care home indicated the provider worked well with partners to meet people’s individual needs and risks, other feedback indicated improvements in the quality of care plans, risk assessments and governance needed to be more timely.
The provider worked with health and social care partners to ensure people achieved positive outcomes and continued to work with partners to drive improvements at the service.
Learning, improvement and innovation
Staff told us the provider had a positive approach to learning and improving the service. One staff member told us, “After the last CQC inspection, I felt like we couldn’t get out of the situation however I feel like we have really improved as a service with the new management team.” The management team explained they used good practice identified from the provider’s other services and from partner agencies to drive improvements at Grove Court.
The provider was working with the local authority and partner agencies to make service improvements. The provider’s quality assurance staff worked closely with the operations manager and interim care home manager to make improvements to the service.